Maternal and Child Heath new client form

Privacy statement

The City of Port Phillip Maternal and Child Health Service provides a high-quality service that respects a clients’ right to confidentiality and privacy and meets all legal requirements. The following information outlines how Council will collect, store and use personal and health information provided by you to deliver a high level of care and support for your family.

Personal and Health Information Privacy Statement

The Maternal & Child Health (MCH) Nurses will create a health record for your child that will require the collection of:

Name, address, contact details and information about your child’s health and development.
Information about parent’s health and wellbeing, relevant care plans, referrals advised and outcomes will also be recorded.

The health record for your child will be stored in the Child Development Information System (CDIS). Further information about CDIS can be found at the Victorian Maternal and Child Health Service.

Client information will not be shared with anyone and will remain confidential unless you consent to the release of information, or if required by law (such as a medical emergency, if it is subpoenaed, or as a mandated professional).Council is obligated to ensure that all personal and health information is managed confidentially and stored securely complying with the Children Legislation Amendment (Information Sharing) Act 2018, Privacy and Data Protection Act 2014, Health Records Act 2001, Council’s Privacy Policy and Health Records Policy.

Child information

First name *

Last name *

Date of birth *

Sex *

FemaleMaleIntersexPrefer not to say

Country of birth *

Is the child of Aboriginal or Torres Strait Islander origin *

NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait Islander

Current street addressPlease include the unit number if applicable

Suburb *

Postcode

Preferred contact number for Maternal Child Health nurse appointments *

Is an interpreter required? *

YesNo

What language? *

Primary care giver

Relationship to child

First name *

Last name *

Date of birth *

Gender *

FemaleMaleIntersexPrefer not to say

Best contact phone number *

Current address *

Same as aboveDifferent from above

Street address

Suburb *

Postcode

Country of birth

Would you like to add details of a second care giver?

Care giver 2 relationship to child

Care giver 2 first name

Care giver 2 last name

Care giver 2 date of birth

Care giver 2 gender

FemaleMaleIntersexPrefer not to say

Care giver 2 best contact phone number

Care giver 2 email address

Care giver 2 current address

Same as aboveDifferent from above

Care giver 2 street address

Care giver 2 suburb

Care giver 2 postcode

Care giver 2 country of birth

Consent and submit

I have been provided information and understand how and why certain information about me and my family may be collected and stored for the provision of Maternal and Child Health Services. I understand that this information will be handled in accordance with the Children Legislation Amendment (Information Sharing) Act 2018, Privacy and Data Protection Act 2014 (VIC) and the Health Records Act 2001.

I agree *